[Stiff neck--what to consider]

Many conditions are associated with neck stiffness. Because of the threatening consequences, bacterial meningitis needs special consideration. The sensitivity of the physical examination is discussed: absence of fever, neck stiffness and altered mental status excludes the diagnosis of bacterial meningitis. Lumbar punction with cerebrospinal fluid examination remains the pivotal diagnostic procedure. A previous CT-scan to exclude increased intracranial pressure is indicated only in special risk situations and delayed antibiotic treatment must be avoided. Ceftriaxon is the standard empiric treatment in immunocompetent adult patients. According to the risk for pneumococcal resistance addition of vancomycin or rifampicin is indicated.